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GENERAL PROGRAM FILE New Change Edit _ (PROGS) revised 5/21/43 <br /> FACLLITT ID 7 � � � ,3 FACILITY NAME < <br /> RECORD IDR spa y PRIOR SWEEPS/CCW f1 <br /> _ DAIRY: Grade A _ Grade B _ Nilk Dlspaaer _ Number of Cmtairxra in MUM-1106d Unit <br /> _ FOOD: Restaurant _ Market _ Coanlssary_ Kohl to Food __ ProdUCO Stand __ Ica Plant _ <br /> Seating Capacity SQ Ft Market Wood Prep. T / N <br /> Temporary Food Facility __ Special Food Event __ Verdirg Machines Nutber of Vending Units <br /> Food Vehicle _ Make License / <br /> Registration D Cotor <br /> i <br /> HAZARDOUS WASTE: Tons Genersted/Yr TIERED PERMIT Facitity : CA _ CE —_ PBR <br /> _ HOUSING: Hotet/Notel No. of hits Jail/Exempt Institution Housing Abatement <br /> Employee Housing _ No. of Employed Approx Data of occupancy _/_ f to _ <br /> _ LLDUID WASTE: Pwper Vehicle Pumper Yard Clueuiul Toilets _ No. Package Tx Plant — <br /> _ MEDICAL WASTE: Primary Care _ Acute Care _ Skilled Nursing _ LO Generator _ 4a Generator <br /> Storage (2-10) _ Storage (11-50) _- Storage ( >50 ) _ Transfer Stu !_ Ltd Hauler __ Vet Clinic <br /> VV RECREATIONAL HEALTH: Pool/Spa _ Number of Pools Out of Service Pool Naturel Bathing Place <br /> ^SITE MITIGATION: Environ Assess _ UST/CAP Loc Nat Waste _ Hat Nat PPL <br /> Other Lead Agency Site Agency: RWDCB,�_ DISC _ NPL Site _ RB/H2D G _ Other <br /> _ SOLID WASTE: Lardf lit Transfer Stu _ Recycling Fee __ Vast* Storage Fee _ AV Waste/Exempt <br /> tette _ <br /> SV Vehicle _ No. Dumpeter _ No• Stationery Co psctor <br /> Yenet <br /> VECTOR CONT0.0L: Poultry Fars_ Max Rurber of Birds <br /> ---- - NIGHT <br /> EMERGENCY NOTIFICATION for this FACILITY and/or PROGRAM DAY <br /> CONTACT 1 : C—) t�—) <br /> CONTACT 2 : (—') ( ) <br /> DESIGNATED EMPLOYEE a '. CN ,r PROGRAM ELEMENT ! ��s. IURREMTEITAIIM ;;��! OF UNITS EPA ID 0: IN � V <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned Owner, operator or egant of same, acknowledge that all site and/or <br /> proiect speeif ie PHS/ERO hourly charges associated with this feel tity or activity, wilt be bitted to the party Identif led as the <br /> BILLING PARTY on this fors. 1 also certify that I have prepared this applicstlon and that the work to be performed will be don <br /> In accordance with all applicable SAN JOAOUIN COUNTYYOrdlrorce Codes and/or Standards and State and/or Federal laws. <br /> APPLICANT'S SIGNATURE <br /> 1 Mal "' Sit _Data- <br /> .41 <br /> applicable, t the owner, operator or agent of maw, of <br /> AUTHOR12ATt�ELEASE MFORNATION: In addition to the above, <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> e- irormental/mita assessment information to SAN JOADUtN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> It Is available and at the ssw time It is provided to w or wry representative. <br /> Fee Amour Amount Paid Date of Payment Payment Type Receipt 0 Cheek 0 Recvd BY <br /> AEHS _l_J__ �_I-- ACR <br /> �� OMIT CLK ��- <br />